How vigilant were we in the diagnosis of peri-operative myocardial infarction before 2022 ESC guidelines?

Abstract

Abstract Background The diagnosis of myocardial infarction (MI) after non-cardiac surgical intervention is complicated due to possible absence of symptoms as well as of objective ECG or echocardiography signs of ischemia. Aim This is a retrospective analysis of the prevalence of clinically diagnosed MI after non-cardiac surgery in two district hospitals with large-scale surgical services in the period of 2017 - 2022. Methods We retrospectively collected study data using electronic hospital records of all patients that underwent surgical operations for 6 years. Peri-operative MI was selected according to code I21 following any surgical procedure and verified by symptoms, elevated TnI, ECG and Echo changes. Results Total 103 028 patients underwent orthopedic, vascular, abdominal, neuro- surgery from 2017 to 2022. We found 45 patients diagnosed with MI, what makes the prevalence of 0,04%. Diagnostic criteria were: median TnI levels 4925 [1171; 13162] ng/L, symptoms [62% had typical anginal pain, 38% felt dyspnea, 22% had no symptoms], ECG changes {40% with ST elevation, 42% with ST depression, 16% bundle branch block}. Three patients (7%) were administered with troponin test before surgery. Patients with peri-operative MI were 81 [70; 86] years old, 49% females, with the history of CAD (42%), hypertension (71%), diabetes (33%), CKD (13%), anemia (38%), atrial fibrillation (33%), heart failure (47%). The duration of anesthesia was from 20 min to 3h 05 min and it was general in most cases. Bleeding requiring blood transfusion was observed in 27% of cases. It is known that 42% of patients used beta-blockers, 22% used statins before the operation, and 33% saw cardiologist in last 5 years. STEMI occurred in 44%, NSTEMI in 38% of patients, in 18% MI was unspecified, PCI was performed in 44%. Patients were transferred to ICU in 78% of cases and in 20% to cardiology ward. In-hospital deaths occurred in 49% of cases. Conclusions Little number of peri-operative myocardial infarctions are recognized in current practice, however, the mortality of these patients is very high. These findings highlights the importance of implementation of non-cardiac surgery guidelines, namely, routine troponin evaluation in high-risk patients.